Public Service

I'm going to tell you a story about the most radical shift in the NHS you've never heard of. After the weekend we've just had, this runs the risk of looking out of touch but the systemic dismantling of funding and governance of public services is very much part of the violence we're now living through. Let me explain.  Last week I went to a conference about Sustainability and Transformation Plans (STPs), held by a well known health policy and research foundation populated by the new generation of blue-suited corporate account managers and a few good people of a clinical persuasion. The beards have gone, but a glance around the room is sober confirmation about the consequences of ‘strong and stable’ leadership on diversity and class participation in public service debates.  At the end of a long air conditioned day of power points about innovation, the head of the NHS Confederation, who as it turns out by pure coincidence is head of an STP in the South West, explains how he manages the massive funding gap. He says, as if amongst friends, ‘well, we’re moving acute care into the prevention and wellbeing sector delivered in the community using student nurses who are really cheap!!!?!”. Then he actually laughs out loud.  Yes, the way that the NHS is planning on stopping people overwhelming their GPs or A&E is by not paying decent wages. Actual healthcare jobs replaced by social prescribing and community empowerment. If you work in mental health this comes as no surprise, where the third sector is filling the health funding and governance gap through the unwaged work of trainees.  As the proofs came in for my book Surviving Work in Healthcare last year there was a moment when I thought about putting a match to the whole manuscript because of the emergence of the Sustainability and Transformation Plans (STPs). Nobody had ever mentioned STPs throughout the whole process of writing this book and yet only a few months later their introduction by stealth threatens to obliterate what remains of patient led care.  In response to the NHS deficit, in 2014 the Chief Executive of the NHS in England, Simon Stevens proposed A Five Year Forward View which aims to maintain quality services through innovation and cost savings in return for additional governmental funding by 2020-21. A key part of this plan is the creation of Sustainability and Transformation Plans (STPs), which despite their progressive name stand to be probably the least sustainable plan for NHS restructuring to date. STPs, clustered in acute and specialist care which represents the main bulk of the NHS deficit, are tasked with eliminating the gap between costs and funding by creating 44 ‘local health systems’ that create ‘footprints’ for planning and delivering care. If they manage to do this in 2016/17 they can access £2.1bn of ‘transformation’ funding, not actually new money but part of the £10bn NHS funding agreed in the 2015 spending review. The main bulk of this £2.1bn will go to emergency care, and smaller pots for efficiencies and transformations in service delivery. The first thing to say is that these are not ‘local’ in any meaningful way. The STPs are massive structures covering on average 1.2 million people, merging local authorities and CCGs. Its hard to see how bringing together an average of five CCGs into one group could possibly lead to more local control over planning and securing good deals with local providers. If the last three decades of neoliberal economics and the consolidation of finances into a smaller number of corporate hands is anything to go by, its hardly going to put commissioning power in the hands of civil society.  Secondly, the timescale for the creation of STPs made it impossible for these local actors to even call a meeting let alone carry out a serious strategic and inclusive exercise. The final STP Delivery Plans were supposed to be submitted on the 21st October 2016. These full plans were not published, rather they were sent to NHS England for revisions, with publication in mid-December. On the 23rd December 2016 CCGs had to sign two year operational contracts with providers, starting on 1 April 2017. Even for the most committed local health campaigner, if you knew about these deadlines the chances of organising a genuine consultation around them were extremely unlikely. These leaves STPs with the Kafkaesque job of ticking the sixty diversity and inclusivity boxes that they are required to do knowing full well that the real stakeholders have been left without any meaningful role to play. At its very best, this offers local health groups the option of a headless chicken approach to health management. At its worst it will lead to a radical decline in patient care and safety.  Now for the really funny bit. The principle requirement for STPs is that the Local Authorities, CCGs and providers that form the main bulk of these STPs have to square the circle of health and social care funding by cutting expenditure enough to stay within their budgets for 2016-2017. If they over spend, and do not improve patient care at the same time they will not be able to get any further ‘transformation’ funding. Funding is dependent on cuts. Campaigning groups that very quickly mobilised around blocking STPs, such as in Liverpool, estimated that the plans include an implicit target to cut NHS spending by a further £25.5bn. They call them Secret Theft Plans or Slash Trash and Plunder. If the books already don't balance,  STPs are just being tasked to cull staff and services by the end of 2017 in order to secure future funding. The easiest way to do this is to pay those shiny tech companies money to digitise as much care as possible and then employ underpaid or unwaged non-clinical roles when only humans will do. Most of this activity does not count as actual care, its tinkering round the edges. I’m reminded of a Fordian industrial relations joke “You can have whatever mental health service you want as long as its online cognitive behavioural guided self-help”. This cuts-dressed-as-innovation is familiar to those health warriors who were involved in the creation of CCGs where cuts in budgets combined with devolution of healthcare provision to local services and penalties for not implementing impossible targets worked very well in shifting the burden of responsibility from the government to local stakeholders. The task of balancing the NHS’s books in one year while at the same time improving patient care is literally impossible leaving STPs with the option of failing or gaming.  Don’t get me wrong, nothing gets my heart beating faster than a working class GP controlling resources across millions of people. I think that’s a good thing. But to pretend that this radical re-shift in managing services is a step towards genuine partnership across services and the co-creation of patient led care is a profound sleight of hand.  Although some good people are tucked away in STP leadership, many are politically naive working with the blue-suited engineers of a profound attack on public service. It’s an actual fact that I’m prone to the paranoias but what is happening here is a concentration of power, not a delegation of it. This strategy of cutting public services by bureaucratic stealth has already taken place in the police, the army, prisons, and schools engineered by the same political leadership now dismantling public health and social care. When a political party talks the talk of governance it's good politics to judge them on the basis of whether they're walking the walk of government.  What is happening right now is a full on passing of the public service buck. When you vote this week, vote for a party that is prepared to govern and fund healthcare, rather than do a state led dump and run on our public services.  Surviving Work in Healthcare: Helpful stuff for people on the frontline has been published by Routledge. Click here quoting code SUR230 to buy a copy for £17.50.